What Is Online Therapy?

Online therapy provides a convenient and often affordable way to access mental health help without requiring you to visit a counseling center or therapist’s office in person. Instead, you can connect with your therapist via video call, phone call and/or text message conversation, depending on your needs and preferences.

Online therapy is a safe space in which you can address topics like depression, anxiety, stress, anger management, insomnia, panic attacks, eating disorders, trauma, relationship issues, life transitions, bereavement and more.

Different online therapy platforms support different methods of therapy delivery, so first consider the way(s) in which you would like to receive help. The best online therapy options in our evaluation were broad telehealth sites that include therapists: Amwell, Doctor on Demand and MDLive. These services mirror a traditional therapy appointment, focusing on live video sessions with a therapist.

Some online therapy platforms allow you to purchase one video therapy session at a time while others require a monthly subscription, which usually includes a single video therapy session a month and access to unlimited text messaging with your therapist. If ongoing communication with your therapist sounds beneficial to you, consider a platform with this subscription option. Just note that “unlimited messaging” means that you can text message your therapist as much as you like, but your therapist might respond only once or twice a day on weekdays.

Many online therapy services have their own mobile apps as well.

Is Video, Phone or Chat Better?

“Each [communication] format plays a significant role in the total therapy process,” says Lisa Henderson, a licensed professional counselor expert at the American Counseling Association and co-founder of Synchronous Health in Nashville, Tennessee. “If you’re doing anything that’s what I would consider deep work—trying to resolve trauma, getting into the roots of addictions or eating disorders, anything where you’re doing a lot of processing—I prefer video. You need to be able to see and read body language.”

Meanwhile, Henderson says texting is fantastic for check-ins around skill building and using those new skills. “Texting is much better for the coaching side when I want to deviate away from the processing side.” Texting or check-ins between live sessions are often used in dialectical behavior therapy to reinforce the client’s practicing of evidence-based skills when they encounter difficult situations.

As far as phone calls go, Henderson suggests this format is best for navigating gray areas. “It’s harder to coach without getting into processing on the phone, but if it’s complicated and you need to work through why something didn’t work, then the phone would certainly be better than texting,” she adds.

The best online therapy platforms connect you with licensed providers, which can include psychiatrists, psychologists, licensed marriage and family therapists, licensed clinical social workers and licensed professional counselors.

How to Choose the Best Online Therapy

It can be challenging to compare online therapy platforms due to their wide range of plans and prices. Based on our research, here are several ways to identify the best online therapy for you:

• Decide the format in which you want to receive therapy. That might be a live video session, phone call, text messaging conversation, live text chat or a combination.
• Look at plan options that best match the amount of interaction you want. For example, if you want live video sessions, know how many you will get a month in the plan, how long they are (30 minutes vs. 50 minutes) and how much it would cost to add extra video sessions in a month.
• Contact customer service to clarify the details if you’re unsure. For example, can you pause a subscription for a week or two? How do you change therapists if you’re not happy with your current provider?
• Understand the refund policy, which isn’t always clear on the online therapy sites. In many cases you can cancel your subscription at the end of a month but you won’t receive a refund for your unused days.
• Make sure you can access the type of provider you want. For example, if you want sessions with a psychiatrist, confirm the service has one available in your state.
• Ask if you can interview therapists to find the right fit. You’ll be sharing intimate details and working through deep issues with this person, so you want to be sure you’re comfortable with them and can build rapport well. You may want to ask them where they received their training, what therapeutic modalities they practice, and what ideas they have about addressing your specific concerns.

Who Is Online Therapy the Best Choice for?

Many people are likely to need some mental health support due to the effects of the COVID-19 pandemic. The number of adults with depression symptoms more than tripled between March 2020 and September 2020—from 8.5% to 27.8%—according to a study published in JAMA.

Certain disorders and issues may be better suited for virtual therapy than others. It’s usually appropriate and effective to address anxiety disorders, body image issues and guilt issues with online therapy. People seeking personal growth and the children of alcoholics can benefit from the online therapy format as well, according to a study in the Journal of Clinical Psychology.

Situations not appropriate for online therapy, according to the study, include:

• Suicidal thoughts.
• Borderline personality disorder.
• Thought disorders, which may include symptoms of delusions, hallucinations and disorganized thinking that are associated with disorders like schizophrenia.
• Medical issues that aren’t well monitored.

Pros and Cons of Online Therapy

Mary Alvord, a psychologist in Maryland who teaches mental health professionals about telehealth, Jay Shore, Ph.D., a psychiatrist and director of telemedicine at the Helen and Arthur E. Johnson Depression Center at the University of Colorado Anschutz Medical Campus, and Lisa Henderson, a licensed professional counselor expert at the American Counseling Association, offer these pros and cons for online therapy. Other sources of this advice include Psychology Today and the American Psychological Association.

Pros

Circumvents mental health stigma. “For people whom stigma is a concern, especially if they live in a tight-knit community, parking their car outside a counseling center or therapy office feels on-display,” Henderson says. “But online therapy is discrete in ways that in-person [therapy] simply isn’t.”

Convenience and safety. If you’re unable to travel safely during bad weather or can’t take time out of your workday to travel to and from a mental health professional’s office, a virtual visit can be a good substitute.

Sense of intimacy. Shore says some patients may prefer their familiar at-home surroundings versus an “artificial clinic environment.” Henderson echoes these sentiments. “In some ways, video is more intimate than being in the same room because we’re in each other’s space,” she says. “You might be in my office, but it’s in my home, so it feels like you’re in my home just as I am in your home. That really bridges a gap, as opposed to being on my turf when you come into my office.”

Similar outcomes. In-person and video visits hold the potential to deliver similar results, according to Shore. Henderson agrees: “We see just as much, if not more, improvement in online therapy settings. Apples to apples, in-person therapy versus telehealth, there’s really no difference between which one is more effective.”

Easier access. For people who live far from the nearest therapist office or counseling center, online therapy can provide a readily available alternative.

Little to no wait time. A virtual appointment may be able to begin on time while an in-office appointment may be delayed by paperwork and other bureaucratic hurdles.

Cons

Nonverbal communication. A therapist may not pick up on a patient’s nonverbal cues during a virtual appointment. Alvord explains that much of our communication is nonverbal. However, Henderson points out that the proximity of the camera lens during video appointments can provide more visual communication through facial expressions than an in-person appointment where a greater physical distance exists between the therapist and the client.

Limited effectiveness for some. Certain patients, such as some children or people with autism spectrum disorder, may not respond well to virtual therapy, Alvord notes. Patients with dementia or other cognitive issues also may not do well in virtual sessions without modifications, such as a caregiver being with the patient, Shore says..

Technology. Some patients’ homes may not be equipped with high-speed internet service, or the patient may not be comfortable with technology, making virtual therapy difficult or even impossible to carry out.

Insurance coverage. In some cases, your health insurance provider may cover an in-person therapy session but may not cover a virtual session. Such policies are constantly changing, though, especially in light of the COVID-19 pandemic. Speak to an agent at your insurance company to confirm what your coverage currently includes.

Looking for an Online Therapist

Alvord suggests asking these questions when selecting an online therapist:

• What are the therapist’s qualifications? Is the therapist a mental health professional licensed in the state where they live or work? How many years have they been in practice?
• Does the therapist specialize in certain areas, topics or issues related to mental health? Do these specialties align with your needs? How many patients have they treated that have concerns similar to yours?
• What modality does the therapist practice from (e.g., cognitive behavioral therapy, psychodynamic therapy, somatic experiencing therapy, etc.)? What specific tools do they have to treat your specific concerns?
• Will the therapist ask you to sign an informed consent agreement? Informed consent educates a patient about treatment risks, benefits and alternatives.
• What would the therapist’s backup plan be in case you’re experiencing a mental health emergency but can’t reach the therapist?
• Does the therapist’s platform comply with privacy security rules laid out by the Health Insurance Portability and Accountability Act (known as HIPAA)?

Regulation of Online Therapy

Regulation of online therapy sites and mobile apps—an area of mental health known as telebehaviorial health or telemental health—is a bit of a hodgepodge.

Both the Food and Drug Administration (FDA) and the Federal Trade Commission (FTC) regulate some, but not all, medical apps. The safety of medical apps “is an emerging public health issue,” say researchers in a 2020 study in the Journal of the American Medical Informatics Association. They called for establishment of “vigilant regulatory frameworks” to govern these apps.

As the FDA “continues to develop a framework for oversight, industry professionals have noted that the agency has taken a hands-off approach for mental health apps in particular,” say researchers in The Regulatory Review, a publication by University of Pennsylvania’s Program on Regulation.

At the state level, regulation typically focuses on doctors who deliver telehealth services, but state agencies have stepped up their regulation of psychologists, counselors and other mental health professionals who use telehealth. For its part, the American Counseling Association emphasizes that counselors who offer telebehavioral services must adhere to state licensing requirements. Many online therapy sites stress that all of their therapists are licensed.

On top of state regulations, compliance with professional ethical standards and HIPAA may come into play with online therapy.

Online therapy also raises questions about regulation when a therapist is in one state and the patient is in another. Most of the time, therapists can only practice in the state they’re licensed, which means their client must be in the same state even if the sessions are virtual–an exception would be if they obtained some type of temporary or provisionary permit with the state board where the client resides. This is important because therapists must abide by rules and regulations overseen by their specific licensing boards, and interstate cases can cause issues in investigating problems involving a therapist’s professional conduct.

Filing an Online Therapy Complaint

If you need to lodge a complaint about an online therapy platform, first alert the site to your concerns. Next, you can reach out to the FDA and FTC. To file a complaint about a specific therapist, contact the agency in your state that’s in charge of licensing the therapist’s profession. Licensing rules vary for psychiatrists, psychologists, therapists and counselors.

3 Questions to Ask Before You Sign Up for Online Therapy

Before you commit to online therapy, ask yourself:

1. Are the Site’s Therapists Licensed?

Some sites market their services as therapy, but those claims may be false or misleading, says the American Psychological Association (APA), because some therapists may not be professionally licensed.

According to the APA, “therapist” and “psychotherapist” are not “legally protected” words in some states, meaning someone who promotes themselves as a therapist may not be licensed. Numerous online therapy providers promote the fact their therapists are licensed.

2. Is Online Therapy the Best Option For Me?

Online therapy may not be right for everyone in every situation. For example, online therapy may not be ideal for people with several mental disorders or who pose a threat to themselves or others, according to a Frontiers in Psychiatry study.

However, research suggests professionals and patients view telehealth favorably and that teletherapy can be effective. “I would say—and have heard some of my clients say, too—that in some ways, online therapy is even a little bit more comfortable than being in the same room,” Henderson says. “And that has implications on people feeling relaxed and opening up.”

3. Does My Insurance Cover Online Therapy?

Private and government-sponsored health insurance don’t cover telehealth services, including online therapy, evenly. The U.S. Department of Health and Human Services says most private health insurance covers at least some telehealth offerings. Meanwhile, Medicare and Medicaid cover telehealth in certain cases.

If an online therapy provider accepts insurance, they can bill your insurer directly. You’ll still be responsible for your copays and deductibles. If the site doesn’t accept insurance, you may be able to submit your bills to the insurer for reimbursement, depending on your plan. You may also need a diagnosis in order to use insurance.

Meanwhile, you may be able to use your health savings account (HSA) or flexible savings account (FSA) to pay for online therapy.

How to Prepare for an Online Therapy Session

Alvord and Shore provide these tips for getting ready for an online therapy session:

• Make sure you’re able to chat with your online therapist in a comfortable space, perhaps even in a car if you’re at work or home and can’t find an otherwise suitable spot.
• If you’re undergoing therapy via video, be sure your surroundings are properly lit so the therapist can clearly see you.
• Check whether your computer, internet connection and other required technology are working properly ahead of your appointment.
• Limit disruptions during your therapy session. For instance, you can hang a sign on the door asking people not to come in during a certain period.

Frequently Asked Questions (FAQs)

Are online therapists legit?

Not all “online therapists” are legit. To be safe, make sure your therapist has licensing in your state, such as a licensed marriage and family therapist or licensed clinical social worker. Many online therapy services will also have psychiatrists and/or psychologists available.

Can an online therapist prescribe medication?

Not all therapists can prescribe medication, regardless of whether you meet with them online or in person. A couple of online therapy services we evaluated have plans that specifically include medication in the pricing.

Sources

• Ettman C, Abdalla S, Cohen G. Prevalence of depression symptoms in US adults before and during the COVID-19 pandemic. JAMA Network Open. 2020;3(9):e2019686.
• A, Zack J, Speyer C. Online therapy: Review of relevant definitions, debates, and current empirical support. Journal of Clinical Psychology. 2004;60(3):269-83.
• A growing wave of online therapy. American Psychological. Accessed 3/18/2021.
• What is autism spectrum disorder? American Psychiatric Association. Accessed 3/18/2021.
• What you need to know before choosing online therapy. American Psychological Association. Accessed 3/18/2021.
• Stoll J, Müller JA, Trachsel M. Ethical issues in online psychotherapy: A narrative review. Frontiers in Psychiatry. 2020;10:993.
• Saba A, Enrico C, Farah M. Safety concerns with consumer-facing mobile health applications and their consequences: a scoping review. Journal of the American Medical Informatics Association. 2020;27(2):330–340.
• Regulating Mobile Medical Applications. The Regulatory Review. Accessed 3/18/2021.
• Shah P, Thornton I, Turrin D, Hipskin J. Informed Consent. Treasure Island, FL: StatPearls Publishing; 2021.
• Professional Association Codes of Ethics and Guidelines On TeleMental Health, E-Therapy, Digital Ethics, & Social Media. Zur Institute website. Accessed 3/18/2021.